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The Compliance Nurse 2 reviews case management and utilization management activities and documentation to ensure adherence to policies, procedures, and regulations and to prevent and detect fraud, waste, and abuse to ensure appropriate course of action. The Compliance Nurse 2 understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. The Compliance Nurse 2 work assignments are varied and frequently require interpretation and independent determination of the appropriate courses of action.

Position Responsibilities

• Ensures mandatory reporting completed.

• Complies, conducts, and summarizes compliance audits/reports to include deficiencies and risks.

• Collects, review records, summarizes issues and analyzes data daily, weekly, monthly, or as needed to assess outcome and operational metrics for the team and individuals to determine appropriate course of action.

• Audits CM medical records and operation for compliance.

• Proficiency in analyzing, tracking, and interpreting data trends, operational guidelines and procedures are adhered to.

• Ensures DMAS Cardinal Care Guidelines, NCQA, CMS, and Humana's Healthy Horizon's Policy and Procedures are followed.

• This is a mainly a virtual position, however, it may require occasional travel for meetings or audits to ensure accreditation is met.

• Ensures auditing is completed timely and communicated with leadership.

• Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed.

• Other duties as assigned per CM or Quality leadership.

Use your skills to make an impact
 

Required Qualifications

• Active Registered Nurse license in the state of Virginia, or obtain a multi-state license a bordering contiguous state that participates in the enhanced licensure, (eNLC) without disciplinary action

• Minimum two, (2) years of auditing experience preferably in a clinical or MCO setting

• Intermediate to Advanced knowledge using Microsoft Office Word, Excel, PowerPoint, navigating multiple systems and platforms and ability to troubleshoot and resolve basic technical difficulties in a remote environment

• Previous experience with Managed Care Organization.

• Ability to work independently under general instructions and with a team

• Exceptional oral and written communication and interpersonal skills

Preferred Qualifications

• Bachelor’s Degree in Nursing

• Medicare/Medicaid, DMAS, CMS, and NCQA experience 

Workstyle:  Remote work at Home

Location: Virginia or reside within 40 miles of one of the following contiguous bordering states - Tennessee, West Virginia, North Carolina, Maryland, or Kentucky

Schedule: Monday - Friday 8:00 AM to 5:00 PM Eastern

Travel: 25% travel within the Commonwealth of Virginia for meetings or compliance assurance audits

Work at Home/Remote Requirements To ensure Hybrid Office/Home associates’ ability to work effectively, the self-provided internet service of Hybrid Office/Home associates must meet the following criteria: at minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is recommended; wireless, wired cable or DSL connection is suggested. Humana will provide Home or Hybrid Home/Office associates with telephone equipment appropriate to meet the business requirements for their position/job. Work from a dedicated space lacking ongoing interruptions to protect member PHI / HIPAA information

SSN Alert Humana values personal identity protection. Please be aware that applicants may be asked to provide their Social Security Number, if it is not already on file. When required, an email will be sent from Humana@myworkday.com with instructions on how to add the information into your official application on Humana’s secure website.

Interview Format As part of our hiring process for this opportunity, we will be using an interviewing technology called HireVue to enhance our hiring and decision-making ability. HireVue allows us to quickly connect and gain valuable information from you pertaining to your relevant skills and experience at a time that is best for your schedule.

Travel: While this is a remote position, occasional travel to Humana's offices for training or meetings may be required.

Scheduled Weekly Hours

40

Pay Range

The compensatio